DISEASE

An epidemic is a sudden disastrous event in the same way as a hurricane, an earthquake, or a flood. Such events reveal many facets of the societies in which they occur. The stress they cause tests social stability and cohesion. Epidemics, however, have their own characteristics, one of which is that while they cause social upheaval they are also caused by it. The massive dislocation brought about by the transformation of agrarian into industrial societies from the end of the eighteenth century in Western states produced its own patterns of epidemic invasions.

disease and disaster: epidemics and society in the nineteenth century

In Britain, for example, up to the late seventeenth century the population grew gradually. The early modern period witnessed new surges in population growth in a society with an exponentially expanding economic base. In the nineteenth century epidemic diseases caused massive levels of mortality in the first industrial society, and yet population growth soared. Toward the end of the nineteenth century Britain began to see a dramatic decline in premature mortality and an increased length of average life. In other Western industrializing societies similar patterns recurred. Changing patterns of economic development were a major factor in bringing about demographic change from the early modern to the modern period, allowing earlier marriage and rising standards of living, which led to increased fertility and less hunger. But can the modern rise of population be accounted for purely by the reduction in famine and malnutrition and improved overall levels of nutritional status? Or has intervention in the spread of infectious disease played an equally important role?

Studying the epidemic streets of nineteenth-century industrializing societies provides one insight into these questions. The sprawling urban world of high-density masses took the lives of innocents more than anything else. Infant death was responsible for a huge proportion of preventable mortality in the nineteenth-century industrial city. Among the most economically deprived who had least access to the facilities that would provide a hygienic environment for infant life, millions of infants died. They succumbed to measles, whooping cough, smallpox, and, above all, diarrhea. Children and young adults died of diphtheria and tuberculosis. Everyone from all age groups caught fever—typhoid and typhus—and the great grim reaper, cholera, brought periodic devastation. Urban proletariats, however, were largely well fed enough throughout the nineteenth century to remain above the level of malnutrition that would effect immunity to these diseases, so what accounts for declining mortality from them as the century wore on? How can this be explained if improved nutrition does not provide the whole answer?

Taking the British case as an example a bit further, the prevention of infantile diarrhea depended upon a clean water supply for washing utensils and maintaining sufficient levels of domestic hygiene. This gradually became available in Britain starting in the late nineteenth century and coincided with the period of mortality decline. Diphtheria, by contrast, needed the temporary isolation of the disease from the school population in order to prevent the disease from spreading. Starting in the 1870s, local health officers in Britain had the power to close schools and isolate victims and their siblings. At this time a number of factors began to converge that increasingly provided a protective environment for all against infectious disease. Newer levels of social stability created the opportunity for masses of the population to settle and control their immediate environments as the pace of industrial growth and urbanization slowed and its infrastructural developments became fixed and functional. Direct interventions to halt the routes of infection had also been operating for a continuous period by this time, namely, the environ-mental and preventive medical reforms of the sanitary and state medical movements. In Britain the preventive idea had been proselytized by new bearers of a professionalized hygienic ideology, medical officers of health, and by the turn of the century this began to have an effect on domestic consciousness, reducing the apathy toward infectious disease and encouraging new practices within the home. Above all a society that had experienced a century of massive economic, social, and technological transition was beginning to solidify and learn to cope with the penalties of expansion. Displaced populations were beginning to settle, social dislocation was reduced, public health intervention had begun to take effect, and infectious disease began to decline.

Two epidemic diseases of the nineteenth century illustrate this process more than any other and have come to characterize the costs of the level of urbanization that accompanied industrialization. Typhus is a disease that flourishes among populations who live under the circumstances of refugees without access to stable, hygienic shelter, clean water, and enough food. It became a persistent feature of poverty among inner-city populations, especially among the migrant and itinerant poor. Typhus is transmitted to humans through the vector of body lice. It attacks people who live in dirty conditions without access to clean surroundings and clothes. It was traditionally associated with jail inmates, armies, and famine victims, all of whom lived under such conditions. In the nineteenth century it was the migrant urban populations who suffered from typhus most. Migration became a defining demographic characteristic of early industrial societies. Agricultural laborers migrated to become industrial workers and members of the industrial proletariat, and Lumpenproletariat often moved more than once during a lifetime to follow the geography of the business cycle. But the populations that migrated to look for work became the poorest and most deprived in the urban environment. They were last in line and had least access to the facilities the city could offer—a stable roof over their heads, clean water, regular employment, and a sufficient income to provide them with an adequate subsistence. They were dirty, hungry, and, in the winter, cold. They became louse-ridden. They were attacked by typhus in droves.

Typhus became a disease that the migrant poor always had with them, but among epidemic disasters of the nineteenth century cholera was king. Asiatic cholera swept through Europe from India like an avenging angel. Caused by waterborne fecal germs, cholera revealed its own story about the social, political, and economic relations of industrial societies. It demonstrated the dysfunction of mass aggregation in the urban environment and the tenuous stability of class relations. Over the course of the century, it stimulated governments into creating policies to improve the environmental conditions that had facilitated its massive pandemic spread. Cholera killed with shocking speed and vicious regularity. At its peak it could wipe out communities in a week. The social-psychological effect of cholera on the nineteenth-century mentality was devastating. It became the symbol of the human costs of exponential industrial and economic growth.

Understanding epidemic disease in industrial society and how to control it required nineteenth-century state and civic authorities to rethink their approaches. Following traditional patterns of quarantine and isolation employed in the control of plague proved inadequate. For one thing, cholera seemed to defy the contagionist theory of disease. It bypassed quarantine procedures and isolation measures, cutting across all traditional barriers erected to protect the community. Miasmatic etiology seemed to offer a more plausible explanation. It could explain cholera's transmission across cordon sanitaires and suggested the answer might be to clean up the environment rather than issue quarantines, which stopped the economic lifeblood of free-market trading societies. As cholera raged among urban communities until late in the nineteenth century, politicians, doctors, and disease theorists fought over how it was caused and how it could be eliminated.

disease, dislocation, and social order

Epidemic disease took the question of population health to a high point on the political agenda of the nineteenth century. Disease became the definitive symbol of the dislocations experienced by industrializing societies.

Numerous scholars who have looked at disease in history, such as William H. McNeill and Alfred W. Crosby, have discovered how it has frequently precipitated widespread social disruption and upheaval and has been a factor in bringing about revolutionary changes. Disease has subsequently been examined as a test of social cohesion at different periods. Much of the scholarly work on nineteenth-century cholera, for example, has set out to demonstrate the link between pandemic waves and revolutionary uprisings. Other scholars have suggested that cholera was the spur to the development of public health administration throughout Europe. More recent studies, however, have challenged this view and have demonstrated how a much broader set of events combined with epidemic episodes to stimulate the growth of public health administrations.

Did disease precipitate social disruption or was it precipitated by it? Certainly cholera pandemics coincided with times of severe disorder and unrest in nineteenth-century Europe. The first European epidemic of 1831 to 1832 followed the tail end of the revolutions on the European continent in 1830 and took place during the most violent period of civil disorder resulting from political agitation for parliamentary reform in Britain in 1832. The second pandemic of 1848 to 1849 began in the year of revolutions in Germany and France, and the 1854 epidemic followed the outbreak of the Crimean War (1853–1856). The 1866 epidemic occurred as the German federation was demolished after Otto von Bismarck's war with Austria, and the Second Empire fell in France as cholera spread during 1871. At the time of the last wave of cholera in 1892, there were major disturbances in Russia and Poland.

Cholera created violence and rioting, especially during the epidemic of 1831 to 1832. In Russia the peasant masses rioted against their feudal lords in the belief that there was a deliberate campaign to poison the water as part of a Malthusian conspiracy to kill off the poor and relieve the state of the financial burden of poverty. Riots occurred in Paris against medical officials for similar reasons. In England the cholera riots of 1832 were directed at doctors, this time in the belief that the medical profession was encouraging the spread of cholera to obtain bodies for anatomical dissection.

It is easy to understand why cholera should have created such unrest if one considers how European authorities generally responded to it. Most authorities when faced with the prospect of the epidemic in 1831 simply employed the old quarantine procedures used in feudal times against the plague. That is, they set cordon sanitaires with military enforcement, closed down public meeting places, and sealed off cities and towns. But these measures, which were passively accepted by the masses living under absolute states in the seventeenth and eighteenth centuries, were not so easily imposed upon a generation that had witnessed the rise of radical democratic popular movements, following the lead of the American and French Revolutions. The coincidence of inexplicable mass mortality and the sudden appearance of government officials, medical officers, and military troops aroused popular suspicion and unrest. The bourgeois authorities became the object of conspiracy theories among the poor and were attacked as the agents of a class war. The homes of noblemen and the offices of health authorities were ransacked throughout Prussia, and officials were murdered in Paris. In Britain doctors were attacked in Bristol, not for being agents of the state, but as the result of the popular conceptions about their sinister, macabre trade in dead flesh.

Cholera, however, spread though Europe largely as an effect of social disorder rather than being the cause of it. It did follow dearth and famine, but there is only limited evidence that malnutrition lowers the stomach acid level and weakens resistance. Much more significantly it followed the movements of troops and the disruption of war. Cholera was first transmitted from its original home in India by the military campaign fought by the Marquis of Hastings against the Marathas in 1817. In 1831 the Russian war against Poland spread the disease from Asia to Europe. British troops spread it to Portugal, and in 1866 cholera was spread by the war between Austria and Italy. In 1854 French troops transferred the disease again eastward when they landed in Gallipoli during the Crimean War. It is easy to understand why troop movements spread the disease. War produces mass movements of refugee populations who abandon their homes only to end up living in appalling, unsanitary encampments. Troops themselves are cramped and confined in grossly unsanitary camps that rapidly spread disease to the nearest civilian settlement. Demobilized soldiers carry disease back to their civilian homes. Above all, overcrowded prisoner-of-war camps became fever hubs.

Apart from war, the increasing mobility of populations through the expansion of trade during the nineteenth century was the most important vehicle for the spread of cholera. The waterborne disease followed canal routes and rivers and was carried by sailors, traders, and shipping workers. Service occupations involving water, such as cleaning and washing and innkeeping, were always the first groups to succumb.

Cholera was also spread by social dislocation and subsequently exacerbated it. This pattern of social dislocation and epidemic spread is equally demonstrated for another acute infection characteristic of the times, typhus. Typhus has a long history of being associated with war and famine, frequently flourishing in military encampments and jails. Typhus, however, became almost endemic among some urban populations during the nineteenth century. Again, this reflected the social dislocation occurring in the everyday life of towns and cities that were undergoing rapid, large-scale economic and social change based on incessant population migration. The precise relationship of cause and effect between typhus and industrialization is, nevertheless, complex and difficult to untangle.

Taking the example of one city, the patterns of typhus epidemics in Victorian London are not immediately easy to explain. A steady decline of the disease occurred without any apparent correlation to hygiene or nutrition. There is no nutritional basis to immunity to typhus, although hunger is connected with it indirectly, and it followed periods of dearth and famine in the eighteenth century. Urban typhus, however, did not follow the slumps of the business cycle in Victorian Britain, and therefore different circumstances must account for its unpredictable pattern. Typhus epidemics in Victorian London were precipitated by the much more complex phenomenon of urban crisis rather than nutritional crisis. Urban crisis describes the combination of a number of features of deprivation, including hardship from political and economic conflicts, such as strikes and lockouts, and home-lessness and overcrowding resulting from slum clearance and demolition for the construction of railways. Such forces can produce urban stress that a disease such as typhus can exploit.

Continuing outbreaks of typhus in London occurred between 1861 and 1869. Throughout the late 1850s the workers in the building trades in London had been locked out by their masters for refusing to not join a union. The industrial unrest caused widespread hardship and malnutrition. It coincided with a massive program of housing clearance for the construction of the railways. Certain areas of London were, by the 1860s, filled with families living in grossly overcrowded conditions—up to twelve people in one room—hungry and without a clean or regular water supply.

Typhus is a rickettsia disease that is spread by the human body louse. The rickettsias multiply in the body of the louse and are ejected in its feces. Humans contract it from scratching and breaking the surface of the skin. The disease can remain active in the feces dust of the louse for a long period and therefore can be breathed in from house dust in a dwelling that has not been disinfected. Hungry people feel the cold more and in the middle of winter are less likely to change their linen or wash their clothes. In these conditions they are much more likely to harbor lice and increase the opportunity for infection (leading to the flourishing of typhus in the winter months).

It was in the areas of great overcrowding where typhus became epidemic in the 1860s and then suddenly and dramatically declined after 1870. What accounted for the decline? First, the demolition program of the railways ceased, and municipal building programs began distributing the slum populations to new housing. The fever-nest slums were subsequently demolished. Second, a clean and constant water supply became available beginning at the end of the 1860s, which enhanced the chances of improved personal and domestic hygiene. Third, London's economy stabilized, and the laboring poor experienced a comparative period of minimum prosperity. Typhus clearly followed the social dislocation that resulted from urban crisis in Victorian London. The pattern of infection among Irish immigrants demonstrates this relationship most clearly. Contemporary moralists and medical investigators presumed that typhus was indigenous to the Irish and referred to it as Irish fever. But the epidemics occurred in London before they occurred in Dublin. The fact that many Irish immigrants lived in infected localities reflects the way that this group more than any other suffered the deprivations of urban crisis and were the most vulnerable to its ravages.

framing history

Nineteenth-century typhus and cholera epidemics reveal how disease framed and is framed by history. Its biological existence was directly determined by social, economic, and political conditions, and it in turn brought about historical changes in those relationships. Epidemic diseases characterized the downside to economic and urban growth. They also revealed some of the intricate social changes taking place in industrial society.

Epidemic infections declined toward the end of the nineteenth century, creating the conditions for the demographic transformation of the increasingly aging and chronically sick populations that characterized advanced industrial societies by the middle of the twentieth century. The interventions of the state into the means by which epidemic infections were transmitted among mass urban populations and impoverished rural populations played a crucial role in their decline. Furthermore, the role of the state in providing for the public health altered the profile of disease.

See alsoChadwick, Edwin; Cholera; Cities and Towns; Economic Growth and Industrialism; London; Nightingale, Florence; Nurses; Paris; Revolutions of 1848; Smallpox; Syphilis; Tuberculosis.

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Dorothy Porter